The pressure's on

Clinicians have a new system for classifying pressure ulcers and other skin breakdowns, but change also has brought uncertainty about matters pertaining to assessing, coding and billing. Providers are
Clinicians have a new system for classifying pressure ulcers and other skin breakdowns, but change also has brought uncertainty about matters pertaining to assessing, coding and billing. Providers are

Since the National Pressure Ulcer Advisory Panel issued updated staging definitions in spring, long-term care providers have been discerning just what they need to change — and more importantly, when they need to change.

In its first comprehensive update since 2007, the panel rolled out the term “pressure injury,” officially nixing the use of “ulcer,” while also adding two new classes of injuries.

But the changes were announced without guidance from the Centers for Medicare & Medicaid Services, creating a murky situation in which clinical and billing practices might not easily align.

“It's like the NPUAP and the CMS people cannot get at the same table together,” says Mary Madison, RN, RAC-CT, CDP,  Clinical Consultant for Long-Term/Senior Care for Briggs Healthcare. “Initially, there won't be a fallout. You won't receive a deficiency because CMS hasn't adopted or adapted.”

Yet many providers are worried about just that, especially as wound care specialists begin to follow the new guidelines in earnest and new phrasing makes it to tougher to translate clinical charting into reimbursable codes.

“What I'm really seeing is there's a lot of confusion about how quickly these changes need to be implemented,” says Eula
Reynolds, RN, MSN, CWS, director of clinical education for DermaRite. “The concern is how surveyors are going to interpret the changes. Will it put [providers] at risk for F-Tags [citations]?”   

The Joint Commission has adopted the new terminology and the NPUAP and CMS are in discussions. No one has issued any definite deadlines except for the National Database of Nursing Quality Indicators' commitment to be on board by 2017.

Because staging still remains essentially the same, the NPUAP reassured providers in August that they don't need to rush into expensive systematic changes that might need to be redone to conform with CMS in a year or two.

Reynolds says she's not sure that message is understood.

A NPUAP task force spent 16 months reviewing literature, the latest international guidance and questions from the panel's own members about staging. The April consensus conference allowed more than 400 attendees to examine proposed definitions and vote on clarifications, revisions and additions.

But even well-informed change doesn't come without controversy.

“Advancing the standards of care through evidence-based practice is never easy nor simplistic,” says Martie Moore, RN, chief nursing officer at Medline and a member of NPUAP's corporate advisory council. “The new changes will advance patient care. There is still much that we need to learn on not only how to keep skin healthy, but what the evidence points at for best practices in treatment and healing.”

Payment concerns

The Wound, Ostomy and Continence Society is still in the process of developing a formal position statement in favor of the latest version, but spokesman Chris Carchidi said members received an email in June expressing support.

On its website, the society acknowledged that the changes are causing “some short-term issues in regards to coding (and) payment.”

NPUAP's most frequently asked question since the consensus conference relates to how providers will be paid for pressure injury treatment since it is not in the ICD-10 offerings.

Moore suggests adding “injury” to policies along with helpful synonyms in parentheses. Healthcare providers also should read updated stages, study new illustrations and consider creating skin health initiatives, she says.

Some vendors in the wound care arena are helping customers navigate what will be a drawn-out transition.

“The people most interested in the terminology in our organization have been our field nurses, who are always enthusiastic about new developments,” says Glenn Paul, vice president of marketing for Gentell. “However, we must be careful about a wholesale change in terminology because it IS confusing. This is the NPUAP — not CMS — and CMS is the payer, so the industry will probably continue to use its language until CMS makes the change.”

Gentell has changed the wound treatment section of its Wound Advisor product, which includes an algorithm and treatment guidelines for pressure injuries.

At Briggs, Madison had already edited about two dozen tracking and assessment forms bought in bulk by care providers, and she's identified others — including MDS item sets and the RAI user's manual — that will need to be updated once CMS weighs in.

Big changes expected

Genice Hornberger, RN, product manager for PointClickCare, says organizations using an electronic heath record to standardize assessments are waiting for CMS to decide how they'll overhaul diagnoses.

She predicts the cost likely will be highest for paper-based facilities, which could have to replace thousands of pre-printed forms.

With PointClickCare's Skin and Wound app, customers won't have to pay for a new version; they'll just download it and go.

“At the earliest, we'll see these changes October 1, 2017,” Hornberger says. “When we know a change is coming and we start planning for the change, we're ready to go and we can help our customers prepare.”

Attorney Norris Cunningham also is preparing, especially for how jurors might interpret the word “injury” in wrongful death cases. He leads the litigation practice group at Hall, Render, Killian, Heath & Lyman.

Unlike “ulcer,” he said an “injury” is more likely to conjure up “this idea that some untoward event happened or that harm was done.”

“Lots of folks are really nervous,” says Cunningham, who spoke out against some of the changes during the consensus meeting. “It's a legitimate concern for them to have, but I don't want to overstate it. It doesn't greatly tilt the landscape toward plaintiffs.”

In a webinar this summer, task force co-chair Laura Edsberg, Ph.D., director of the Center for Wound Healing Research, said there was “overwhelming support for the term ‘injury.'”

But the panel didn't use the consensus method to get approval for all of its changes, an issue it addressed in a set of FAQs published in May. It said the term “injury” was more inclusive of all 6 stages. Madison, Paul and Reynolds all agree on that point.

“It matches up fine to what's actually happening,” Madison says, noting that many providers and materials had already been using the more general term “wound.” “Ulcer can also have a negative connotation, or it might seem to imply that you're talking about broken skin.” 

But Reynolds said she's heard from clinicians, directors of nursing and administrators who worry that juries would jump to conclusions about inadequate care.

NPUAP said the attorneys it consulted agreed it's up to them to explain the new definition within clinical contexts established by medical professionals.

The panel's statements also note “injury” is associated with other conditions commonly seen in long-term care, including acute kidney injury (formerly acute kidney failure) and spinal cord injury.

Cunningham says that's a dangerous comparison because spinal injuries land people in rehabilitation settings. Pressure injuries occur during a doctor's care.

‘Cleaning up'

PointClickCare's Hornberger says the change could provide “a light lift” for education of patient families — if addressed correctly.

“In a family member's mind, it's a wound, a bedsore,” she says. “That said, educating a family on terminology might help them understand what the injury is, how to care for it and prevent it, particularly if or when they'll be caring for the resident at home.”

Viewed as a whole, the revisions should be seen as a “cleaning up” that provides more specificity for clinicians, Madison says.

The updates include additional definitions for medical device-related pressure injuries and mucosal membrane pressure injuries.

The mucosal definition covers injuries inside a body cavity, such as tubes in the nose, bite blocks or catheters.

Eighty-three percent of those attending the consensus conference wanted to see a new definition that listed a medical device as a cause of pressure injury.

“Just by calling awareness to it, saying it aloud, that is an ‘Aha!' moment,” says Madison.

Julia Melendez, RN, BSN, JD, CWOCN, is national clinical director for Joerns. By early September, the company had completed a new staging guideline resource for clinicians, and begun delivering educational presentations, both in person and via webinar, to discuss the new language and implications. 

“The more effectively clinicians are able to identify the tissue types in the wound and communicate with other members of the interdisciplinary team about treatment for these wounds through our documentation, the more effectively we can treat and ultimately heal them,” she says.